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Case Study Report: Patient Provider Telehealth Network – Using Telehealth to Manage Chronic Disease

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Case Study Report: Patient Provider Telehealth Network – Using Telehealth to Manage Chronic Disease HEALTH IT AND HEALTH DISPARITIES Patient Provider Telehealth Network – using telehealth to improve chronic disease management PREPARED FOR: U.S. Department of Health and Human Services Washington, D.C. PREPARED BY: NORC at the University of Chicago 4350 East-West Highway 8th Floor Bethesda, MD 20814 JUNE, 2012 CONTRACT NUMBER: HHSP2337005T/OS38984 This report was prepared by NORC at the University of Chicago under contract to the Office of the National Coordinator for Health IT (ONC) and the Health Resources and Services Administration (HRSA). The findings and conclusions of this report are those of the authors and do not necessarily represent the views of ONC, HRSA, or the U.S. Department of Health and Human Services. NORC | Understanding the Impact of Health IT in Underserved Communities and those with Health Disparities Case Study Report: Patient Provider Telehealth Network – using telehealth to manage chronic disease “This program is different from other programs. We always hear from patients, ‘This was the first time anyone has cared enough to help me figure it out.’ This health IT program is about longer-term relationship building and working with the patient to give them the encouragement that they can do this and make the associations.” – RCCHC Provider Report Summary Members of the NC-based Patient Provider Telehealth Network use a telehealth remote Intervention monitoring system to monitor key health indicators for rural, high-risk patients throughout the and Setting state. Members leverage their electronic health records (EHRs) to share data collected through remote monitoring devices with patients’ providers. Target Uninsured or underinsured high-risk individuals with diabetes, cardiovascular disease, and Population hypertension Technology Software-based telehealth remote monitoring systems and corresponding health indicator Description measure devices. Phase 1 (2006 – 2009): NC Health and Wellness Trust Fund Commission ($360,000) in 2006; additional funding (2007-2009) from Kate B. Reynolds Charitable Trust, the Obici Foundation, Pitt County Foundation, and the Roanoke Chowan Community Benefit to expand Funding RCCHC’s remote monitoring program and implement a post discharge remote monitoring and and Start- chronic care management for diabetes patients at Roanoke Chowan Hospital. up Phase 2 & 3 (2009 – present): NC Health and Wellness Trust Fund Commission ($870,000); Funding (amount unknown) from Duke Endowment to continue in-house at Piedmont (2010). Health Resources and Services Administration (HRSA) Telehealth Network Grant (2010 – present): $250,000 Content analysis using NVivo for a series of in-person discussions with the following individuals from Roanoke Chowan Community Health Center (RCCHC) and Piedmont Health Services, Inc. (Piedmont): RCCHC and Piedmont Chief Executive Officers and Chief Medical Officers Data and RCCHC Telehealth Clinical Network Director Analysis Piedmont Director of Care Management (Telehealth Administrator) Piedmont Director of IT RCCHC and Piedmont physicians, registered nurses, and care managers Individuals who obtain services from RCCHC and Piedmont clinics Introduction of health information technology (health IT) tools through a trusted source is fundamental to successful adoption. Key Take- Remote monitoring can dramatically increase patient engagement and result in improved Aways outcomes for chronic disease self-management and reductions in hospital-related costs. Interoperability with other IT systems and reimbursement for telehealth care are critical to further adoption and sustainability. CASE STUDY: Patient Provider Telehealth Network| 2 NORC | Understanding the Impact of Health IT in Underserved Communities and those with Health Disparities Introduction A Federally Qualified Health Center (FQHC) located in rural northeastern North Carolina, Roanoke Chowan Community Health Center (RCCHC) operates clinics in Ahoskie, NC, Colerain, NC, and Murfreesboro, NC. As one of the only health care providers in the area, RCCHC currently provides care to approximately 21,000 individuals, more than half of the patients in the service area. The RCCHC serves a primarily Black population (70%) with a high chronic disease burden and very low incomes.i Their service area includes four of the poorest counties in the nation. One program administrator estimated 20% of RCCHC patients live 100% below the Federal Poverty Level (FPL)ii and the majority of the patients served have no or inadequate insurance. In 2006, RCCHC received Phase I grant funding from the NC Health and Wellness Trust Fund (HWTF) Health Disparities Initiative to conduct a three-year feasibility study of the center’s Patient Provider Telehealth Network (PPTN). The study sought to determine the impact of telehealth monitoring on clinical and financial outcomes for RCCHC’s patients with cardiovascular disease, diabetes, and hypertension. In 2008, the PPTN expanded to provide remote monitoring services to patients enrolled in Piedmont Health’s (Piedmont) PACE program (Program of All Inclusive Care for the Elderly). Piedmont, also an FQHC, operates six clinics – two semi-urban and four rural – serving patients across 14 counties. The clinics operate in Carrboro, NC, Moncure, NC, Prospect Hill, NC, Siler City, NC, and two locations in Burlington, NC. Piedmont provides care to largely uninsured or underinsured patients. One provider reported 76% of patients live at or below 100% of the FPL and an additional 20% live at or below 200% of the FPL. Piedmont primarily serves members of racial or ethnic minority groups. Hispanics make up approximately half of their population and Blacks make up an additional 20%. Piedmont administrators also noted a growing Burmese population. In 2010, Piedmont received funding to self-monitor their patients previously monitored by RCCHC. Between 2009 and 2010, the PPTN expanded to eight additional health centers and two hospitals as a result of additional funding received from the HWTF Health Disparities Initiative and a telehealth network grant from the Health Resources and Services Administration (HRSA). As of early 2011, RCCHC monitored and managed patients across 28 – primarily rural – counties in North Carolina.iii Rural populations and rural minority populations in particular, experience marked disparities in health and health care access. Compared to providers in strictly urban areas, rural health care providers serve an older and poorer population and a population more likely to experience fair or poor health and chronic conditions. According to the Agency for Healthcare Research and Quality (AHRQ) 2010 National Healthcare Quality and Disparities Report, rural residents do not receive recommended preventive services at the same rate as their urban counterparts and on average report fewer visits to health care providers.iv Potential benefits of using telehealth remote monitoring technology. Use of telehealth remote monitoring technologies can improve clinical management of chronic diseases, increase cost- savings, and expand access to quality health care services. Many telehealth interventions demonstrate utility as a health care delivery tool for underserved populations in rural communities where geographic distance and lack of specialists pose challenges to traditional delivery of health services.v The application of telehealth technologies enables earlier detection and quicker assessments using evidence- based health information.vi Earlier recognition of health problems promises to improve quality and cost- efficiency of care through decreased emergency department (ED) visits and hospital readmissions. Additionally, as demonstrated at RCCHC and Piedmont, programs using telehealth technology improve CASE STUDY: Patient Provider Telehealth Network| 3 NORC | Understanding the Impact of Health IT in Underserved Communities and those with Health Disparities patient engagement and self-management to foster increased adherence to treatment plans through patient education. Key functionality and uses. RCCHC and Sources of Funding Piedmont use several remote monitoring applications Phase 1 (2006 – 2009): NC Health and as part of the PPTN. Currently in use for Phase 2 is Wellness Trust Fund Commission ($360,000) in IDEAL LIFE’s Body Manager, a software-based 2006. Additional funding (2007-2009) from: telehealth system, which includes a digital body o Kate B. Reynolds Charitable Trust, weight scale and blood pressure device. Placed in o The Obici Foundation, participating patients’ homes, the IDEAL LIFE o Pitt County Foundation, and remote monitoring telehealth system transmits daily o Roanoke Chowan Community Benefit readings from patients’ blood pressure and scale Phase 2 & 3 (2009 – present): NC Health and devices as encrypted data through landline or cellular Wellness Trust Fund Commission ($870,000); connection platforms to the IDEAL LIFE secure web o Funding (amount unknown) from Duke server. Telehealth nurse care managers monitor Endowment to continue in-house at patients’ data via the system’s dashboard and contact Piedmont (2010) patients with abnormal readings via phone to conduct HRSA Telehealth Network Grant (2010 – a nursing assessment and/or provide patient present): $250,000 education. The monitoring dashboard allows care managers to create summary reports and trend patient data longitudinally. As part of the PPTN, if a telehealth care manager determines there is need for a change in a patient’s medical regime during the nursing assessment, they can share the health data
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